<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496804038
Report Date: 02/13/2025
Date Signed: 02/21/2025 02:16:17 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/06/2024 and conducted by Evaluator Christi Coppo
COMPLAINT CONTROL NUMBER: 21-AS-20240906084230
FACILITY NAME:FOREVER SARAHS ELDERLY CARE CORPFACILITY NUMBER:
496804038
ADMINISTRATOR:SAMPSON, JASMINEFACILITY TYPE:
735
ADDRESS:4313 HOEN AVETELEPHONE:
(310) 531-6049
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY:4CENSUS: 3DATE:
02/13/2025
UNANNOUNCEDTIME BEGAN:
02:13 PM
MET WITH:CaregiverTIME COMPLETED:
02:52 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
*amended report to change complaint finidngs*
Staff does not ensure resident's grooming needs are being met.
Administrator is not present in the facility for sufficient amount of hours.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
*Amended report to change complaint findings*
Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to deliver findings for the above allegation and was greeted by caregiver. Licensee Jenero Jefferson was not available to come to the facility, was not available by phone and their voicemail box was full, so LPA could not leave a message. LPA sent text to licensee to advise purpose of visit

Staff does not ensure resident's grooming needs are being met. Complaint alleges the resident’s (R1) toenails are so long. During investigation, LPA reviewed caregiver notes written on 8/3/24-9/12/24; however, dates of caregiver notes inconsistent, not present for all days. Notes indicate that R1 refused showering once but was noted as showering seven times, once as result of soiling themselves, no mention of trimming toenails. Notes indicated two [2] instances of grooming other than showering (i.e. shaving and cutting hair), but no mention of foot care or toenail clipping. During investigation, LPA received photographic evidence that

Continued on 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 21-AS-20240906084230
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: FOREVER SARAHS ELDERLY CARE CORP
FACILITY NUMBER: 496804038
VISIT DATE: 02/13/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from 9099...

*Amended report to change complaint findings*

R1’s feet were extremely swollen and had turned the colors black, purple, and red. This discoloration covered the entirety of R1’s toes and lower foot, extending up the entire outer side of their foot to their ankle. R1’s toenails appear not to have been groomed as evidenced by nail overgrowth and yellow crusty substance covering toenails. During investigation, LPA interviewed staff, staff reported to LPA that they noticed that R1 and R2 needed help with grooming, R1 didn't know how to verbalize needing help, and the staff would help R1, but not with as much care as R1 needed. Staff reported to LPA that staff let the licensee know that R1 needed help with better grooming, staff told licensee many times; however, staff reported that the licensee would acknowledge it and then brush it off, no action ever taken. On 1/3/25 LPA was present in facility and noticed R1 has a strong smell of urine. Staff advised LPA that R1 refuses to shower. Caregiver notes log not present. Based on LPA’s interviews, observations and photographic evidence, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D.

Continued on 9099C(2)...

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20240906084230
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: FOREVER SARAHS ELDERLY CARE CORP
FACILITY NUMBER: 496804038
VISIT DATE: 02/13/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from 9099C...

Administrator is not present in the facility for sufficient amount of hours. During investigation, LPA interviewed staff, staff reported that Administrator would come every 2 weeks and licensee would come every other month. Staff also reported another caregiver as doing the administrating. Per LPA observation, Administrator not typically present at facility. LPA has visited facility four [4] times between the dates of August and November, only one of which occasions was the Administrator of record present or present in the city of Santa Rosa. At the time of this complaint filing, the Administrator of record was Jasmine Sampson. Jasmine’s primary city of residence is over 300 miles away from the facility. As of the date of this report, the facility has no administrator of record. Based on LPA’s observation and interview, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with caregiver. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with caregiver and a copy of this report was given.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 21-AS-20240906084230
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: FOREVER SARAHS ELDERLY CARE CORP
FACILITY NUMBER: 496804038
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/14/2025
Section Cited
CCR
80074(c)
1
2
3
4
5
6
7
**Amended to remove deficiency
1
2
3
4
5
6
7
**Amended to remove deficiency
8
9
10
11
12
13
14
8
9
10
11
12
13
14
Type A
02/14/2025
Section Cited
CCR
80078(a)
1
2
3
4
5
6
7
80078 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs.
This requirement is not met by licensee as evidenced by: Based on LPA interview
1
2
3
4
5
6
7
Facility licensee to contact Sonoma County ombudsman for next date of personal rights training course and report date to LPA by plan of correction due date. Both facility licensee and all facility staff to complete personal rights training
8
9
10
11
12
13
14
and record review, the licensee did not comply with the section cited above in that R1 ‘s grooming needs were not met, which poses an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
course with Sonoma County Ombudsman on the date reported to LPA.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20240906084230
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: FOREVER SARAHS ELDERLY CARE CORP
FACILITY NUMBER: 496804038
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/14/2025
Section Cited
CCR
85064(e)
1
2
3
4
5
6
7
85064 Administrator Qualifications and Duties (e) The administrator shall be on the premises the number of hours necessary to manage and administer the facility in compliance with applicable law and regulation.
This requirement is not met by licensee as evidenced by: Based on LPA interview
1
2
3
4
5
6
7
Facility to submit candidate for Administrator and all required paperwork: LIC215, LIC500, LIC308, LIC501, detailed employment/education history, copy of current and active Administrator certificate, and board resolution by plan of correction due date
8
9
10
11
12
13
14
and observation, the licensee did not comply with the section cited above in that an administrator was not on the premises the number of hours necessary to manage and administer the facility in compliance with applicable law and regulation, which poses an immediate health, safety, or personal rights risk to persons in care.
.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5